CHAPTER 5 :MOOD DISORDERS - DEPRESSION
TYPES OF DEPRESSIVE DISORDERS
1. MAJOR DEPRESSIVE DISORDER (MDD)
DEFINITION OF DEPRESSION
Depression is an alteration in mood that is expressed by feelings of sadness, despair,
and pessimism. There is a loss of interest in usual activities, and somatic symptoms may
be evident. Changes in appetite and sleep patterns are common
DESCRIPTION OF DEPRESSION

The course of MDD is variable

Patients with MDD experience substantial pain and suffering and psychological,
social, and occupational disability during their depression

The symptoms often interfere with the patients’ social and occupational functioning
and sometimes may include psychotic features

Delusional or psychotic major depression is a severe form of Mood Disorder that is
characterized by delusions or hallucinations

Depression affects almost 10% of the population worldwide

At least 60% of those people can expect to have a second episode

People who have had a second episode of MDD have 70% chance of having a third
episode

Those who have three episodes have a 90% chance of more future episodes

The DSM IV TR diagnosis will identify:
1. The degree of severity of symptoms (mild, moderate, or severe
2. If there is evidence of psychotic or catatonic features
3. If there is a seasonal pattern of the episode
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The DSM-IV-TR diagnostic criteria for major depressive disorder
A. Five (or more) of the following symptoms have been present during the same TwoWeek period and represent a change from previous functioning; at least one of the
symptoms is either (1) depressed mood or (2) loss of interest or pleasure
1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad or empty) or observation made by others (e.g.,
appears tearful). NOTE: In children and adolescents, can be irritable mood.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day (as indicated either by subjective account or
observation made by others)
3. Significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month), or a decrease or increase in appetite nearly
every day. NOTE: In children, consider failure to make expected weight gains
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day (observable by others,
not merely subjective feelings of restlessness or being slowed down)
6. Fatigue or loss of energy nearly every day
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick)
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others), recurrent thoughts of
death (not just fear of dying)
9. Recurrent suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide
B. There has never been a manic episode, a mixed episode, or a hypomanic episode that
was not substance or treatment induced or due to the direct physiological effects of
a general medical condition
C. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)
E. The symptoms are not better accounted for by bereavement (i.e., after the loss of a
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loved one), the symptoms persist for longer than 2 months or are characterized by
marked functional impairment, morbid preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or psychomotor retardation.
MAJOR DEPRESSIVE DISORDER (MDD) SUBTYPES
1. MDD with psychotic features

indicates the presence of delusion such as delusions of guilt, or being punished
for sins, somatic delusions of horrible disease or body rotting, delusions of
poverty or going bankrupt

Or the presence of hallucinations usually auditory, voices berating person for
sins or shortcomings
2. MDD with Postpartum onset

Onset within 4 weeks of childbirth

Can present with or without psychotic features

Severe rumination or delusional thoughts about infant increased risk of harm to
infant
3. MDD with seasonal characteristics (Seasonal Affective Disorder SAD)

Indicates that episodes mostly begin in Autumn or Winter and remit in Spring

Characterized by anergia, hypersomnia, overeating, weight gain, and a craving
for carbohydrates

Responds to phototherapy (light therapy)

Phototherapy treats seasonal affective disorder (SAD) by stimulating the
production of retinal dopamine and suppressing the production of retinal
melatonin (hormone of darkness)
4. MDD with chronic feature

Indicates MDD lasting 2 years or longer
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2- DYSTHYMIA DISORDER (DD)
DESCRIPTION
- Characteristics of DD are similar to those of major depressive disorder but milder
- Individuals with DD describe their mood as sad or “down”
- In DD, there is no evidence of psychotic symptoms
- The essential feature of DD is a chronically depressed mood (Irritable mood in
children or adolescents) for most of the day, more days than not, for at least 2 years
(1 year for children and adolescents).
- The diagnosis is identified as:
1. Early onset: Occurring before age 21 years
2. Late onset: Occurring at age 21 years or older
- Although DD patients suffer from social and occupational distress, it is usually not
severe enough to need hospitalization unless the patient become suicidal
- DD patients are at risk of developing MDD as well as other psychotic disorders
- Differentiating MDD from DD is difficult because both have similar symptoms
- The main differences are in the duration and the severity of the symptoms
DYSTHYMIA DISORDER (DD) SUBTYPES
1. DD and MDD with atypical features

Indicate mood reactivity:
o Can be cheered with positive events
o Rejection sensitivity (pathological sensitivity to perceived interpersonal
rejection)

These features present throughout life and result in functional impairment

Other symptoms include: hypersomnia and hyperphagia.
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3. OTHER DEPRESSIVE DISORDERS
DESCRIPTION

The following disorders have no DSM-IV-TR official diagnostic category

It provides a set of research criteria to promote further study of these disorders
1. PREMENSTRUAL DYSPHORIC DISORDER

PDS characterized by more severe symptoms than Premenstrual Syndrome
(PMS)

Symptoms begin toward last week of luteal (secretory) phase and are absent in
the week following menses (it is the latter phase of the menstrual cycle that
begins with the formation of the corpus luteum and ends in either pregnancy or
luteolysis

The essential features include:
1. Markedly depressed mood
2. Excessive anxiety
3. Mood swings
4. Persistent and marked anger or irritability
5. Anergia
6. Overeating
7. Difficulty concentrating
8. Feeling of being out of control or overwhelmed
9. Decreased interest in activities during the week prior to menses and
subsiding shortly after the onset of menstruation

Somatic complaints, such as headache, edema, backache, and breast tenderness,
as well as changes in appetite and sleep patterns, are common

There is no DSM-IV-TR Diagnostic criteria for Premenstrual Dysphoric Disorder
(PDD), only research criteria
2. MIXED ANXIETY DEPRESSION

Prevalence of 5%

Characterized by significant functional disability
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
Criteria include at least 1 month of persistent Dysphoric mood, with possible
hypervigilance, difficulty concentrating, fatigue, low-self esteem, irritability,

All these symptoms causing significant distress or impairment in functioning
3. RECURRENT BRIEF DEPRESSION

Meets criteria for depressive episode, but episodes last 1 day to 1 week

Depressive episode must reappear at least once per month over 12 months or
more

Carries a high risk for suicide
4. MINOR DEPRESSION

Characterized by sustained depressed mood without the full depressive
syndrome

Pessimistic attitude and self-pity are required for the diagnosis

Maybe chronic and maybe complicated by a superimposed major depressive
episode.
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TREATMENT OF DEPRESSIVE DISORDERS
ANTIDEPRESSANTS
INDICATIONS:

Antidepressant medications are used in the treatment of the following
disorders:
1. Major depression with melancholia or psychotic symptoms
2. Depressive phase of bipolar disorder
3. Depression accompanied by anxiety
4. Dysthymia Disorder
5. Depression associated with organic disease, alcoholism, schizophrenia, or mental
retardation

Effects of treatment with Antidepressants
1. Elevate mood
2. Increase physical activity
3. Increase mental alertness
4. Improve appetite and sleep
5. Restore interest or pleasure in usual daily activities previously enjoyed
MODE OF ACTION

Depression results from a decrease in the concentration of the following
monoamine neurotransmitter to a level insufficient to stimulate the receptors
1. Norepinephrine (Noradrenalin)
2. Serotonin (5 Hydroxytriptamine)
3. Dopamine

Research indicates that by inhibiting the breakdown of the monoamine
neurotransmitters or inhibiting their reuptake to the pre-synapses at the neuron
level in the brain, mood can be effectively elevated and improved.
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CONTRAINDICATIONS/PRECAUTIONS

Hypersensitivity to antidepressants

Acute recovery phase of myocardial infarction

Individuals with angle-closure glaucoma (Narrow-Angle Glaucoma)

Special attention and close observations should be given to elderly people with
hepatic, renal, or cardiac insufficiency when starting them on Antidepressants

Caution: As these drugs take effect, and mood begins to improve, the individual may
have increased physical energy enough to carry out a suicide that he planned when
he was depressed. Suicide potential often increases as the level of depression
decreases. The nurse should be particularly alert to sudden improvement in mood
CLASSIFICATIONS OF ANTIDEPRESSANT

Antidepressants generally fall into four types:
1. Tricyclic Antidepressants (TCAs)
2. Monoamine Oxidase Inhibitors (MAOIS)
3. Serotonin-Specific Reuptake Inhibitors (SSRIs)
4. Serotonin-Norepinephrine-Reuptake Inhibitors (SNRI)
5. Hetrocyclic Antidepressants
1. TRICYCLICS ANTIDEPRESSANTS
a. Amitriptyline (Elavil)
b. Imipramine (Tofranil)
c. Clomipramine (Anafranil)
d. Trimipramine (Surmontil)
Side effects most commonly occur with Tricyclic Antidepressants:
1. Blurred vision, Constipation, Urinary retention, Orthostatic hypotension,
Tachycardia; arrhythmias, Photosensitivity, Weight gain, Reduction of seizure
threshold
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2. MONOAMINE OXIDASE INHIBITORS (MAOIS)

Commonly used MAOIs:
a. Isocarboxazid (Marplan)
b. Phenelzine (Nardil)
Side effects most commonly occur with MAOIs:
1. Hypertensive crisis:

A 14-day interval is recommended between use of Tricyclic Antidepressants drugs
and MAOIs drugs

Life threatening hypertensive crisis may occur with concurrent use of certain
medications and certain foods substances that contain Tyramine

High Tyramine containing foods:
a. Aged cheeses (cheddar)
b. Red wines
c. Smoked and processed meats (salami, pepperoni)
d. Caviar
e. Corned beef
f. Chicken or beef liver
g. Soy sauce,

Moderate Tyramine containing foods:
a. Yogurt
b. Avocados
c. Bananas
d. Beer
e. White wine, coffee, colas, tea, hot chocolate
f. Chocolate

Low Tyramine containing foods:
a. Cream cheese
b. Figs

Symptoms of hypertensive crisis include:
- Severe occipital headache
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- Palpitations
- Nausea & vomiting
- Fever & sweating
- Marked increase in blood pressure
- Chest pain and coma.

Treatment of hypertensive crisis:
- Discontinue drug immediately
- Monitor vital signs
- Administer short-acting antihypertensive medication
- Use external cooling measures to control hyperpyrexia
3. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)

Most commonly used SSRIs:
a. Citalopram (Celexa)
b. Fluoxetine (Prozac)
c. Fluvoxamine (Luvox)
d. Sertraline (Zoloft)
Side effects most commonly occur with SSRIs:
1. Hypertensive crisis can occur if SSRIs are used within 14 days of MAOIs.
2. Insomnia and agitation
3. Headache
4. Weight loss (may occur early in therapy)
5. Sexual dysfunction
Serotonin syndrome:

Occurs when treating with two drugs that increase the availability of Serotonin
in the brain. Most frequent symptoms include changes in mental status,
restlessness, hyperreflexia, tachycardia, labile blood pressure, diaphoresis,
shivering, and tremors.

Treatment: Discontinue the drug immediately. The physician will prescribe
medications to block serotonin receptors, relieve hyperthermia and muscle
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rigidity, and prevent seizures. Artificial ventilation may be required. The
condition will usually resolve on its own once the offending medication has been
discontinued. However, if the medication is not discontinued, the condition can
progress to a more serious state and become fatal
4. SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

Most commonly used SNRIs:
a. Venlafaxine (Effexor)
b. Duloxetine (Cymbalta)
HETROCYCLIC ANTIDEPRESSANTS

Most commonly used Heterocyclic Antidepressants:
a. Bupropion (Zyban; Wellbutrin)
b. Maprotiline (Ludiomil)
c. Mirtazapine (Remeron)
d. Trazodone (Desyrel)
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NURSING CARE PLANNING FOR PATIENTS RECEIVING ANTIDEPRESSANTS
Diagnoses

Example of nursing diagnoses may be considered for clients receiving therapy with
antidepressant medications:
1. Risk for suicide related to depressed mood
2. Risk for injury related to side effects of sedation, lowered seizure threshold,
orthostatic hypotension, photosensitivity, arrhythmias, hypertensive crisis,
or serotonin syndrome.
3. Constipation related to side effects of the medication.
Planning/Implementation

The plan of care should include monitoring for the following side effects from
antidepressant medications:
1. Dry mouth: offer the client sugarless candy, ice, frequent sips of water. Strict oral
hygiene is very important
2. Sedation: request an order from the physician for the drug to be given at bedtime.
Request that the physician decrease the dosage or perhaps order a less sedating
drug. Instruct the client not to drive or use dangerous equipment while experiencing
sedation.
3. Nausea: medication may be taken with food to minimize GI distress.
4. Discontinuation syndrome:
- All classes of antidepressants have varying potentials to cause
discontinuation syndromes.
- Abrupt withdrawal following long-term therapy with SSRIs may result in
dizziness, lethargy, headache, and nausea.
- Fluoxetine is less likely to result in withdrawal symptoms because of its long
half-life.
- Abrupt withdrawal from Tricyclic drugs may produce hypomania, cardiac
arrhythmias, and panic attacks.
- The discontinuation syndrome associated with MAOIs includes confusion,
hypomania, and worsening of depressive symptoms.
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- All antidepressant medication should be decreased gradually to prevent
withdrawal symptoms (weaning)
Client/Family Education

Patient Continue to take the medication even though the symptoms have not subsided.

The therapeutic effect may not be seen for as long as 4 weeks. If after this length of
time no improvement is noted, the physician may prescribe a different medication.

Use caution when driving or operating dangerous machinery. Drowsiness and
dizziness can occur. If these side effects become persistent or interfere with
activities of daily living, the client should report them to the physician. Dosage
adjustment may be necessary.

Not stop taking the drug abruptly. To do so might produce withdrawal symptoms,
such as nausea, vertigo, insomnia, headache, malaise, and nightmares.

If taking a Tricyclic, use sun-block lotion and wear protective clothing when
spending time outdoors. The skin may be sensitive to sunburn.

Report occurrence of any of the following symptoms to the physician immediately:
sore throat, fever, malaise, yellowish skin, unusual bleeding, easy bruising,
persistent nausea/vomiting, severe headache, rapid heart rate, difficulty urinating,
anorexia/weight loss, seizure activity, stiff or sore neck, and chest pain.

Rise slowly from a sitting or lying position to prevent a sudden drop in blood
pressure.

Take frequent sips of water, chew sugarless gum, or suck on hard candy if dry mouth
is a problem. Good oral care (frequent brushing, flossing) is very important.

Not consume the following foods or medications while taking MAOIs: aged cheese,
wine (especially Chianti), beer, chocolate, colas, coffee, tea, sour cream, beef/chicken
livers, canned figs, soy sauce, overripe and fermented foods, pickled herring,
preserved sausages, yogurt, yeast products, broad beans, cold remedies, diet pills. To
do so could cause a life-threatening hypertensive crisis.

Avoid smoking while receiving Tricyclic drugs. Smoking increases the metabolism of
Tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect.

Not drink alcohol while taking antidepressant therapy. These drugs potentiate the
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effects of each other.

Not consume other medications (including over-the- counter medications) without
the physician’s approval while receiving antidepressant therapy. Many medications
contain substances that, in combination with antidepressant medication, could
precipitate a life-threatening hypertensive crisis.

Notify the physician immediately if inappropriate or prolonged penile erections
occur while taking Trazodone (Desyrel). If the erection persists longer than 1 hour,
seek emergency room treatment. This condition is rare, but has occurred in some
men who have taken trazodone. If measures are not instituted immediately,
impotence can result.

Be aware of possible risks of taking antidepressants during pregnancy. Safe use
during pregnancy and lactation has not been fully established. These drugs are
believed to readily cross the placental barrier; if so, the fetus could experience
adverse effects of the drug. Inform the physician immediately if pregnancy occurs, is
suspected, or is planned.

Be aware of the side effects of antidepressants. Refer to written materials furnished
by health care providers for safe self-administration.

Carry a card or other identification at all times describing the medications being
taken.
Outcome Criteria/Evaluation
The following criteria may be used for evaluating the effectiveness of therapy with
antidepressant medications:
a. The patient has not harmed self.
b. The patient has not experienced injury caused by side effects such as hypertensive
crisis, photosensitivity, or serotonin syndrome.
c. The patient exhibits vital signs within normal limits.
d. The patient manifests symptoms of improvement in mood (brighter affect,
interaction with others, improvement in hygiene, clear thought and communication
patterns).
e. The patient willingly participates
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